Texas 2009 - 81st Regular

Texas House Bill HB1889 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	81R2819 KCR-D
2	2	By: Davis of Harris H.B. No. 1889
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to the electronic transmission of certain information by
8	8	and to health benefit plan issuers.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Section 1213.002, Insurance Code, is amended to
11	11	read as follows:
12	12	Sec. 1213.002. ELECTRONIC SUBMISSION OF CLAIMS AND OTHER
13	13	INFORMATION. (a) The issuer of a health benefit plan by contract
14	14	may require that a health care professional licensed or registered
15	15	under the Occupations Code or a health care facility licensed under
16	16	the Health and Safety Code:
17	17	(1) electronically submit a health care claim or
18	18	equivalent encounter information, a referral certification, or an
19	19	authorization or eligibility transaction; and
20	20	(2) communicate electronically with the health
21	21	benefit plan issuer concerning information not otherwise described
22	22	by Subdivision (1).
23	23	(a-1) The health benefit plan issuer shall comply with the
24	24	standards for electronic transactions required by this section and
25	25	established by the commissioner by rule.
26	26	(b) The issuer of a health benefit plan by contract shall
27	27	establish a default method to submit claims and other information
28	28	in a nonelectronic format if there is a system failure or failures
29	29	or a catastrophic event substantially interferes with the normal
30	30	business operations of the physician, provider, or health benefit
31	31	plan or its agents. The health benefit plan issuer shall comply
32	32	with the standards for nonelectronic transactions established by
33	33	the commissioner by rule.
34	34	SECTION 2. Chapter 1274, Insurance Code, is amended to read
35	35	as follows:
36	36	CHAPTER 1274. ELECTRONIC TRANSMISSION OF CERTAIN HEALTH BENEFIT
37	37	PLAN INFORMATION [ELIGIBILITY AND PAYMENT STATUS]
38	38	SUBCHAPTER A. GENERAL PROVISIONS
39	39	Sec. 1274.001. DEFINITIONS. In this chapter:
40	40	(1) "Enrollee" means an individual who is eligible for
41	41	coverage under a health benefit plan, including a covered
42	42	dependent.
43	43	(2) "Health benefit plan" means a group, blanket, or
44	44	franchise insurance policy, a certificate issued under a group
45	45	policy, a group hospital service contract, or a group subscriber
46	46	contract or evidence of coverage issued by a health maintenance
47	47	organization that provides benefits for health care services. The
48	48	term does not include:
49	49	(A) accident-only or disability income insurance
50	50	coverage or a combination of accident-only and disability income
51	51	insurance coverage;
52	52	(B) credit-only insurance coverage;
53	53	(C) disability insurance coverage;
54	54	(D) coverage only for a specified disease or
55	55	illness;
56	56	(E) Medicare services under a federal contract;
57	57	(F) Medicare supplement and Medicare Select
58	58	policies regulated in accordance with federal law;
59	59	(G) long-term care coverage or benefits, nursing
60	60	home care coverage or benefits, home health care coverage or
61	61	benefits, community-based care coverage or benefits, or any
62	62	combination of those coverages or benefits;
63	63	(H) coverage that provides limited-scope dental
64	64	or vision benefits;
65	65	(I) coverage provided by a single service health
66	66	maintenance organization;
67	67	(J) coverage issued as a supplement to liability
68	68	insurance;
69	69	(K) workers' compensation insurance coverage or
70	70	similar insurance coverage;
71	71	(L) automobile medical payment insurance
72	72	coverage;
73	73	(M) a jointly managed trust authorized under 29
74	74	U.S.C. Section 141 et seq. that contains a plan of benefits for
75	75	employees that is negotiated in a collective bargaining agreement
76	76	governing wages, hours, and working conditions of the employees
77	77	that is authorized under 29 U.S.C. Section 157;
78	78	(N) hospital indemnity or other fixed indemnity
79	79	insurance coverage;
80	80	(O) reinsurance contracts issued on a stop-loss,
81	81	quota-share, or similar basis;
82	82	(P) liability insurance coverage, including
83	83	general liability insurance and automobile liability insurance
84	84	coverage; or
85	85	(Q) coverage that provides other limited
86	86	benefits specified by federal regulations.
87	87	(3) "Health benefit plan issuer" means a health
88	88	maintenance organization operating under Chapter 843, a preferred
89	89	provider organization operating under Chapter 1301, an approved
90	90	nonprofit health corporation that holds a certificate of authority
91	91	under Chapter 844, and any other entity that issues a health benefit
92	92	plan, including:
93	93	(A) an insurance company;
94	94	(B) a group hospital service corporation
95	95	operating under Chapter 842;
96	96	(C) a fraternal benefit society operating under
97	97	Chapter 885; or
98	98	(D) a stipulated premium company operating under
99	99	Chapter 884.
100	100	(4) "Health care provider" means:
101	101	(A) a person, other than a physician, who is
102	102	licensed or otherwise authorized to provide a health care service
103	103	in this state, including:
104	104	(i) a pharmacist or dentist; or
105	105	(ii) a pharmacy, hospital, or other
106	106	institution or organization;
107	107	(B) a person who is wholly owned or controlled by
108	108	a provider or by a group of providers who are licensed or otherwise
109	109	authorized to provide the same health care service; or
110	110	(C) a person who is wholly owned or controlled by
111	111	one or more hospitals and physicians, including a
112	112	physician-hospital organization.
113	113	(5) "Participating provider" means:
114	114	(A) a physician or health care provider who
115	115	contracts with a health benefit plan issuer to provide medical care
116	116	or health care to enrollees in a health benefit plan; or
117	117	(B) a physician or health care provider who
118	118	accepts and treats a patient on a referral from a physician or
119	119	provider described by Paragraph (A).
120	120	(6) "Physician" means:
121	121	(A) an individual licensed to practice medicine
122	122	in this state under Subtitle B, Title 3, Occupations Code;
123	123	(B) a professional association organized under
124	124	the Texas Professional Association Act (Article 1528f, Vernon's
125	125	Texas Civil Statutes);
126	126	(C) a nonprofit health corporation certified
127	127	under Chapter 162, Occupations Code;
128	128	(D) a medical school or medical and dental unit,
129	129	as defined or described by Section 61.003, 61.501, or 74.601,
130	130	Education Code, that employs or contracts with physicians to teach
131	131	or provide medical services or employs physicians and contracts
132	132	with physicians in a practice plan; or
133	133	(E) another entity wholly owned by physicians.
134	134	Sec. 1274.002. RULES. (a) The commissioner shall adopt
135	135	rules as necessary to implement this chapter.
136	136	(b) Before adopting rules under this section, the
137	137	commissioner shall consult and receive advice from the technical
138	138	advisory committee on claims processing established under Chapter
139	139	1212.
140	140	SUBCHAPTER B. ELIGIBILITY AND PAYMENT STATUS INFORMATION FOR HEALTH
141	141	CARE PROVIDERS
142	142	Sec. 1274.051 [1274.0015]. EXEMPTION. This subchapter
143	143	[chapter] does not apply to a single-service health maintenance
144	144	organization that provides coverage only for dental or vision
145	145	benefits.
146	146	Sec. 1274.052 [1274.002]. TRANSMISSION OF ENROLLEE
147	147	ELIGIBILITY AND PAYMENT STATUS. (a) Each health benefit plan
148	148	issuer shall, upon the participating provider's submission of the
149	149	patient's name, relationship to the primary enrollee, and birth
150	150	date, make available telephonically, electronically, or by an
151	151	Internet website portal to each participating provider information
152	152	maintained in the ordinary course of business and sufficient for
153	153	the provider to determine at the time of the enrollee's visit
154	154	information concerning:
155	155	(1) the enrollee, including:
156	156	(A) the enrollee's identification number
157	157	assigned by the health benefit plan issuer;
158	158	(B) the name of the enrollee and all covered
159	159	dependents, if appropriate;
160	160	(C) the birth date of the enrollee and the birth
161	161	dates of all covered dependents, if appropriate;
162	162	(D) the gender of the enrollee and the gender of
163	163	each covered dependent, if appropriate; and
164	164	(E) the current enrollment and eligibility
165	165	status of the enrollee under the health benefit plan;
166	166	(2) the enrollee's benefits, including:
167	167	(A) whether a specific type or category of
168	168	service is a covered benefit; and
169	169	(B) excluded benefits or limitations, both group
170	170	and individual; and
171	171	(3) the enrollee's financial information, including:
172	172	(A) copayment requirements, if any; and
173	173	(B) the unmet amount of the enrollee's deductible
174	174	or enrollee financial responsibility.
175	175	(b) Information required to be made available under this
176	176	section may be made available only to a participating provider who
177	177	is authorized under state and federal law to receive personally
178	178	identifiable information on an enrollee or dependent.
179	179	Sec. 1274.053 [1274.003]. CERTAIN CHARGES PROHIBITED. A
180	180	health benefit plan issuer may not directly or indirectly charge or
181	181	hold a physician, health care provider, or enrollee responsible for
182	182	a fee for making available or accessing information under this
183	183	subchapter [chapter].
184	184	Sec. 1274.054 [1274.004. RULES. (a) The commissioner
185	185	shall adopt rules as necessary to implement this chapter.
186	186	[(b) Before adopting rules under this section, the
187	187	commissioner shall consult and receive advice from the technical
188	188	advisory committee on claims processing established under Chapter
189	189	1212.
190	190	[Sec. 1274.005]. WAIVER OF CERTAIN PROVISIONS FOR CERTAIN
191	191	FEDERAL PLANS. If the commissioner, in consultation with the
192	192	executive commissioner of health and human services, determines
193	193	that a provision of Section 1274.052 [1274.002] will cause a
194	194	negative fiscal impact on the state with respect to providing
195	195	benefits or services under Subchapter XIX, Social Security Act (42
196	196	U.S.C. Section 1396 et seq.), or Subchapter XXI, Social Security
197	197	Act (42 U.S.C. Section 1397aa et seq.), the commissioner [of
198	198	insurance] by rule shall waive the application of that provision to
199	199	the providing of those benefits or services.
200	200	SUBCHAPTER C. COMMUNICATIONS WITH ENROLLEES
201	201	Sec. 1274.101. ELECTRONIC TRANSMISSION OF ENROLLEE
202	202	DOCUMENTS AUTHORIZED. (a) Except as provided by Subsection (b), a
203	203	health benefit plan issuer may electronically provide an enrollee
204	204	with any document to which the enrollee is entitled.
205	205	(b) A health benefit plan issuer must provide an enrollee
206	206	with a paper copy of any document to which the enrollee is entitled,
207	207	if the enrollee requests in writing that documents be provided to
208	208	the enrollee in paper form.
209	209	SECTION 3. Section 1213.003, Insurance Code, is repealed.
210	210	SECTION 4. The change in law made by this Act applies only
211	211	to a health benefit plan that is delivered, issued for delivery, or
212	212	renewed on or after January 1, 2010. A health benefit plan that is
213	213	delivered, issued for delivery, or renewed before January 1, 2010,
214	214	is covered by the law in effect at the time the health benefit plan
215	215	was delivered, issued for delivery, or renewed, and that law is
216	216	continued in effect for that purpose.
217	217	SECTION 5. This Act takes effect September 1, 2009.